Provider Demographics
NPI:1427517929
Name:GONZALES, CARISSA ANDRADE
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:ANDRADE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18560 VANOWEN ST UNIT 30
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-5303
Mailing Address - Country:US
Mailing Address - Phone:747-998-7677
Mailing Address - Fax:
Practice Address - Street 1:16955 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-4542
Practice Address - Country:US
Practice Address - Phone:818-343-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17728225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW250885299OtherAETNA